🧠 Stroke Education Module

Definition: Blood clot forms in artery supplying blood to brain

Characteristics:

• Most common type of ischemic stroke
• Often occurs during sleep or early morning
• Usually preceded by TIA
• Associated with atherosclerosis

Subtypes:

• Large-vessel thrombosis: Affects larger arteries (carotid, vertebral, MCA)
• Small-vessel thrombosis (Lacunar): Affects small penetrating arteries

Definition: Blood clot or debris forms elsewhere and travels to brain

Characteristics:

• Second most common type
• Sudden onset during activity
• Often affects middle cerebral artery (MCA)
• No warning signs

Common Sources:

• Atrial fibrillation (most common cardiac source)
• Myocardial infarction
• Valvular heart disease
• Carotid artery stenosis

Definition: Bleeding directly into brain tissue

Characteristics:

• Most common type of hemorrhagic stroke
• Higher mortality rate than ischemic stroke
• Often associated with hypertension
• Sudden onset with severe headache

Common Causes:

• Chronic hypertension (most common)
• Cerebral amyloid angiopathy
• Anticoagulant therapy
• Arteriovenous malformations (AVM)
• Trauma

Definition: Bleeding in space between brain and skull (subarachnoid space)

Characteristics:

• Sudden, severe "thunderclap" headache
• Often described as "worst headache of my life"
• May cause loss of consciousness
• High risk of rebleeding

Common Causes:

• Ruptured cerebral aneurysm (most common)
• Arteriovenous malformation (AVM)
• Head trauma
• Blood disorders

Most important modifiable risk factor

• Increases stroke risk by 4-6 times
• Target: <120/80 mmHg for stroke prevention
• Contributes to both ischemic and hemorrhagic strokes
• Often called "silent killer" - no symptoms

Nursing Management: Regular BP monitoring, medication compliance, DASH diet education, stress management

Leading cardiac cause of stroke

• Increases stroke risk by 5 times
• Responsible for 15-20% of all strokes
• Blood pools in atria → clot formation → embolism
• Strokes from AFib tend to be more severe

Prevention: Anticoagulation therapy (warfarin, DOACs), rate/rhythm control

• Doubles stroke risk
• Damages blood vessels over time
• Often coexists with other risk factors (HTN, obesity)
• Target HbA1c: <7% for most patients

Management: Glucose control, medication compliance, diet, exercise, regular monitoring

• Doubles stroke risk
• Damages blood vessel walls
• Increases blood clotting
• Reduces oxygen in blood
• Secondhand smoke also increases risk

Good News: Risk decreases significantly within 2-5 years of quitting

• High Cholesterol: LDL >130 mg/dL increases atherosclerosis risk
• Obesity: BMI >30 increases risk, especially central obesity
• Physical Inactivity: Sedentary lifestyle doubles risk
• Poor Diet: High sodium, saturated fats, low fruits/vegetables
• Excessive Alcohol: >2 drinks/day for men, >1 for women
• Drug Use: Cocaine, amphetamines increase hemorrhagic stroke risk
• Obstructive Sleep Apnea: Triples stroke risk
• Oral Contraceptives: Especially with smoking and age >35

Mechanism: Dissolves blood clot to restore blood flow

Inclusion Criteria:

• Diagnosis of ischemic stroke causing measurable neurological deficit
• Symptom onset <3 hours (or <4.5 hours for select patients)
• Age ≥18 years
• CT scan rules out hemorrhage

Exclusion Criteria (Contraindications):

• Intracranial hemorrhage on CT
• Recent major surgery (<14 days)
• Recent stroke or serious head trauma (<3 months)
• BP >185/110 mmHg (uncontrolled)
• Active bleeding or bleeding disorder
• Platelet count <100,000
• Glucose <50 mg/dL or >400 mg/dL
• INR >1.7 (if on warfarin)
• Use of direct thrombin inhibitors or factor Xa inhibitors within 48 hours

Critical Nursing Care:

• BP Management: Keep <180/105 during and 24 hours after tPA
• Neurological Checks: Every 15 min × 2 hours, then every 30 min × 6 hours, then hourly
• No Anticoagulation: None for 24 hours post-tPA
• No NG tubes, Foley catheters, arterial punctures for 24 hours
• Monitor for bleeding: Intracranial hemorrhage risk is 6-7%

Procedure: Catheter-based clot removal

• Inserted through femoral artery
• Advanced to brain under fluoroscopy
• Clot retrieved using stent retriever or aspiration
• Success rate: 80-90% recanalization

Indications:

• Large vessel occlusion (ICA, MCA, basilar artery)
• NIHSS score ≥6
• Age ≥18 years
• Pre-stroke mRS 0-1 (functionally independent)
• Treatment can be initiated within 6-24 hours

Post-Procedure Nursing Care:

• Monitor groin site for bleeding/hematoma
• Check distal pulses (dorsalis pedis, posterior tibial)
• Keep affected leg straight × 6 hours
• Frequent neurological assessments
• Monitor for reperfusion injury

Antiplatelet Agents:

• Aspirin: 325 mg within 24-48 hours (NOT with tPA)
• Clopidogrel (Plavix): For aspirin allergy or high-risk patients
• Dual antiplatelet therapy: Aspirin + clopidogrel for minor stroke/TIA

Anticoagulation (for cardioembolic stroke):

• Warfarin (Coumadin): Target INR 2-3 for AFib
• DOACs: Apixaban, rivaroxaban, dabigatran (preferred for AFib)
• Initiated after acute phase (48-72 hours)

Goals:

• Maintain adequate cerebral perfusion
• Prevent secondary brain injury
• Optimize neurological function

Interventions:

• Frequent neurological assessments using NIH Stroke Scale (NIHSS)
• Monitor and maintain BP within prescribed parameters
• Position head of bed at 30° to reduce ICP
• Maintain oxygen saturation >94%
• Monitor for signs of increased ICP (decreased LOC, pupil changes, Cushing's triad)
• Administer medications as ordered (anticoagulants, antiplatelets)
• Prevent hyperthermia (increases metabolic demands)

Goals:

• Prevent complications of immobility
• Maintain muscle strength and joint mobility
• Promote independence in ADLs

Interventions:

• Position patient to prevent contractures (functional alignment)
• Turn every 2 hours to prevent pressure injuries
• Begin passive range of motion exercises within 24 hours
• Progress to active ROM as tolerated
• Use splints/orthotics as ordered to prevent footdrop
• Collaborate with physical therapy for early mobilization
• Apply sequential compression devices for DVT prophylaxis
• Support affected limbs when positioning

Types of Aphasia:

• Expressive (Broca's): Can understand but difficulty speaking
• Receptive (Wernicke's): Can speak but difficulty understanding
• Global: Both expression and comprehension impaired

Interventions:

• Speak slowly and clearly using simple sentences
• Face patient when speaking
• Allow adequate time for responses (don't rush)
• Use alternative communication methods (picture boards, gestures)
• Anticipate needs to reduce frustration
• Encourage patient efforts; avoid correcting constantly
• Collaborate with speech-language pathologist
• Educate family on effective communication techniques

Assessment:

• Perform dysphagia screening before oral intake (within 24 hours)
• Observe for signs: coughing, choking, wet voice, drooling
• Monitor gag reflex (though not always reliable)

Interventions:

• Keep patient NPO until swallow screen passed
• Position upright at 90° for meals and 30-60 min after
• Provide thickened liquids as ordered
• Offer small bites and sips
• Place food on unaffected side of mouth
• Eliminate distractions during meals
• Suction equipment at bedside
• Consider NG tube or PEG if dysphagia persists
• Collaborate with speech pathologist for swallow evaluation

Goals:

• Maximize independence in activities of daily living
• Promote patient participation in care
• Prevent learned helplessness

Interventions:

• Encourage patient to do as much as possible independently
• Allow extra time for ADLs
• Use adaptive equipment (button hooks, long-handled shoehorns)
• Teach one-handed techniques
• Break tasks into simple steps
• Provide positive reinforcement for efforts
• Collaborate with occupational therapy
• Educate family on supporting independence (not doing everything for patient)